S.L. 409.13 Art. 27Saving. L.N. 357 of 2010. To the You must information Its purpose before to you, this safety, you scuba diving. Please below by 1. YOU You are You control) You are following You smoke You have a 2. YOU EVER asthma, or exercise any form of history of spaces) epilepsy, prevent history of history of hi

Any licence issued under the the Recreational Diving Service Provider Regulations, 2010 (which are hereby revoked) and which is still valid and effective immediately before such revocation, shall continue to be valid and effective thereafter as if it were a licence granted under the provisions of these regulations. SCHEDULE Regulation 16(1)(b)

Medical Statement Participant: complete this medical statement, which includes the medical history section, prior to enjoying any recreational scuba diving services. is to inform you whether you should be examined by a physician participating in recreational diving training. If any of these conditions apply does not necessarily disqualify you. It only means that, for your own must seek the advice of a physician prior to participating in recreational acknowledge that you have read and understood the information provided initialling each individual point. MUST CONSULT A PHYSICIAN IF: Yes or No Initials pregnant or you suspect you may be pregnant regularly take medications (with the exception of birth over 45 years of age and one or more of the apply high cholesterol level MUST CONSULT A PHYSICIAN IF YOU Yes or No Initials HAD wheezing with breathing or wheezing with lung disease pneumothorax (collapsed lung) chest surgery claustrophobia or agoraphobia (fear of closed or open seizures, convulsions or take medications to them blackouts or fainting (full or partial loss of consciousness) diving accidents or decompression sickness diabetes high blood pressure or take medications to control pressure heart disease ear disease, hearing loss or problems with balance thrombosis or blood clotting disease AWARE THAT I COULD BE UNFIT TO DIVE IF I HAVE Initials DEVELOP ANY OF THE FOLLOWING CONDITIONS: sinusitis, or any breathing problems such as bronchitis and hay migraine or headache surgery within the last six weeks Under influence of alcohol, drugs or medication affecting the ability react Fever, dizziness, nausea, vomiting and diarrhoea Problems equalising such as when popping ears Acute gastric ulcers Pregnancy

Name ................................................................................................................... Address ............................................................................................................... Date of Birth ............................................... I confirm that the answers to the questions above are true and complete.

Signature ............................................. Date ....................................................

Parental / Guardian consent where participant is a minor Name of Parent / Guardian (delete as applicable) .................................................. Address ............................................................................................................... Signature ............................................. Date ....................................................

THIS DECLARATON IS VALID FOR ONE YEAR FRO SIGNATURE